Shadow Health - Tina Jones, Health History
h h h h h h
HealthhHistoryhTipsh&hTricks:h-hTJhHealthhInterview
Student:hHello!h-
hDianahShadow: hHi.hI'mhPreceptorhDiana.hIhwillhexplainhthehdetailshofhthishassignmenthandhyourhobjec ves,h
justhashahpreceptorhwouldhinhrealhlife.hPayhcloseha en onhtohthishinforma onhashithwillhhelphguidehyourhexa
m.hAththehendhofhthishprebrief,hyouhwillhanswerhahshorthques onhabouththehupcominghassignment.hDuringh
thehsimula on,hyouhmayhreturnhtohthesehinstruc onshathanyh mehbyhscrollinghtohthehtophofhyourhtranscript
.
Student:hWhathishthehsitua on?h-hDianahShadow:hYourhpa enthishTinahJones:,hah28-year-
oldhAfricanhAmericanhwomanhwhohhashjusthbeenhadmi edhtohShadowhGeneralhHospitalhforhahpainfulhfooth
wound.hYourhrolehinhthishsimula onhishthathofhahhealthcarehproviderhwhohwillhtakehMs.hJones'hhealthhhistor
y,hahkeyhcomponenthofhherhadmissionhprocess.
Student:hWhatharehmyhobjec veshinhthishassessment?h-
hDianahShadow: hAhhealthhhistoryhrequireshyouhtohaskhques onshrelatedhtohMs.hJones'hpasthandhpresenthhe
alth,hfromhherhcurrenthfoothwoundhtohherhpre-
exis nghcondi ons.hYouhwillhalsohwanthtohreviewhMs.hJones'hsystems,hpsychosocialhhistory,handhfamilyhme
dicalhhistory.hThesehassessmentshtogetherhwillhgivehyouhahcomprehensivehpicturehofhMs.hJones'hoverallhhe
alth.hIfhyouhdiscoverhanyhdiseasehstates,haskhabouthsymptomshandhthehpa ent'shexperienceshofhthem.hYour
hques oninghshouldhcoverhahbroadharrayhofhthehsymptoms'hcharacteris cs.hThroughouththehconversa on,h
youhshouldheducatehandhempathizehwithhMs.hJoneshwhenhappropriatehtohincreasehherhhealthhliteracyhandh
sensehofhwell-
being.hRegardlesshofhwhetherhyouhhavehassessedhMs.hJoneshpreviously,haskhallhques onshthatharehnecessar
yhforhobtaininghahcompletehhealthhhistory.hWhilehyouhshouldhcommunicatehwithhpa entshusinghaccessible,
heverydayhlanguage,hithishstandardhprac cehtohusehprofessionalhmedicalhterminologyheverywherehelse,hsuc
hhashinhdocumen nghphysicalhfindingshandhnursinghnotes.hYouhmayhcompletehthehexamhac vi eshinhanyhor
derhandhmovehbetweenhthemhashneeded.hA erhobtaininghMs.hJones'hhealthhhistory,hyouhwillhcompletehanhi
nforma onhprocessinghac vity.hYouhwillhiden fyhandhpriori zehdiagnoses,hthenhcreatehahplanhtohaddresshth
ehiden fiedhdiagnoses.
Student:hWhathelsehwillhthishexamhinvolve?h-
hDianahShadow: hYouhwillhcompletehnursinghtaskshtohprotecththehpa entshsafety,hprivacy,handhhealth.hYouhca
nhdocumenthyourhfindings,hincludinghvitalhsigns,hinhthehElectronichHealthhRecord.hThishrecordhprovideshnec
essaryhinforma onhforhhealthcarehprofessionalshwhohwillhcon nuehpa enthcare.hBesideshSubjec vehDatahC
,ollec on,handhEduca onhandhEmpathy,hthereharehac vi eshwithinhthehsimula onhthathprovidehvaluablehpr
ac cehforhtheirhreal-worldhcounterparts,hbuththeyharehnothautoma callyhgradedhbyhthehsimula on.
Student:hHowhwillhIhbehevaluated?h-
hDianahShadow: hInhthishassignment,hyouhwillhbehevaluatedhonhyourhSubjec vehDatahCollec on,hashwellhashy
ourhEduca onhandhEmpathy.hYourhsuccesshinhEduca onhandhEmpathyhishbasedhonhwhetherhyouhpromptlyhr
espondha erhiden fyinghahmomenthworthyhofhtherapeu chcommunica on.hThehevalua onhofhyourhintervi
ewhishdependenthonhhowhyouhwordhyourhques onshtherapeu callyhandhpreciselyhandhexplorehallhrelevanth
topicshwithhcomprehensivehbreadthhandhdepth.hYouhwillhalsohbehevaluatedhonhyourhabilityhtohcollecthdatah
andhformhnursinghdiagnoseshinhthehinforma onhprocessinghac vity.hThishassignmenthtakeshonhaveragehbet
weenh90handh110hminutes.hThishexamhmayhtakehlongerhthanhinhrealhlife,hbecausehinhthishsafehsimula on,hst
udentshofhallhexperiencehlevelshcanhtakeh mehtohhonehandhreviewhtheirhskills.hYouhcanhpausehandhresumeht
hehassignmenthathanyh me;hyourhworkhishalwayshsavedhautoma cally.
Student:hHowhdoeshthishassignmenthpreparehmehforhthehrealhworld?h-
hDianahShadow: hInhthishassessment,hyouhwillhbecomehfamiliarizedhwithhthehstructurehandhcontenthofhahheal
thhhistoryhexamhsohthathwithhreal-
lifehpa ents,hyouhcan:hºhaskheffec vehandhcomprehensivehques onshºhobtainhahthoroughhhealthhhistoryhºhe
valuatehthehpa ent'shriskhofhdisease,hinfec on,hinjury,handhcomplica onshºheducatehandhempathizehºhreflec
thonhyourhexperiencehandhiden fyhareashtohimprovehºhiden fyhandhpriori zehnursinghdiagnoseshºhandhdeve
lophahplanhtohaddresshnursinghdiagnoses.
DianahShadow:hInh1horh2hsentences,hanswerhthishques onhtohhelphpreparehforhthehupcominghexam:hWhyhis
hithimportanthtohobtainhahpa ent'shcompletehhealthhhistory?h-
hStudent:hSohthathyouhunderstandhifhthereharehanyhproblemshrelatedhtohtheirhchiefhcomplaint.hAlso,htohhelp
htreaththeirhcurrenthcondi on.
DianahShadow:hTimehtohbegin.h-h
Pa enthExamh-hVitalhSigns:h-
hHeight:h170hcm,hWeight:h90hkg,hBMI:h31,hRandomhbloodhglucose:h238,hTemperature:h102.4°hF,hBloodhpres
sure:h138/90hmmHg,hHearthrate:h90,hRespiratoryhrate:h18,hO2hsat:h98%
Pa enthExamh-hInterview:h-h
Student:hHello,hmyhnamehishCatlain,hIhamhyourhnursehtoday.h-hTinahJones:hHey.
,Student:hCanhyouhconfirmhyourhname?h-hTinahJones:hTinahJones:.
Student:hWhyhdidhyouhcomehinhtoday?h-
hTinahJones:hIhgoththishscrapehonhmyhfoothahwhilehago,handhithgothreallyhinfected.hIt'shkillinghme.
Student:hWhathaddi onalhsymptomshhavehyouhexperienced?h-
hTinahJones:hIhmean,hit'shallhredhandhswollen,handhthere'shpus,hithfeelshhot,hithhurtshlikehhell...hIt'shgothallhthat
hgoinghon.
Student:hCanhyouhratehyourhcurrenthpainhlevelhonhahscalehofh0htoh10?h-
hTinahJones:h...Likehah7.hIthhurtshahlot,hbuthwhateverhpainhmedhthehERhgavehmehishhelpinghahli lehbit.
Student:hPleasehdescribehthehpain.h-hTinahJones:hIt'shthrobbinghandhlike,hsharphifhIhtryhtohputhweighthonhit.
Student:hHowhdidhyouhhurthyourhfoot?h-
hTinahJones:hIhwashchanginghahlighthbulb,handhIhhadhtohusehourhli lehstepstoolhtohreachhit.hMyhfoothslidhoffhth
ehbo omhstephandhithgothallhscrapedhup.hIhdidn'threalizehhowhsharphthehedgehwas!
Student:hHashyourhfoothbeenhdraininghanyhliquids?h-hTinahJones:hYeah,hthere'shdefinitelyhpus.
Student:hWhathcolorhwashthehpus?h-hTinahJones:hIt's...hwhitehorhmaybehoff-white.
Student:hHowhhavehyouhtreatedhthehwound?h-
hTinahJones:hI'vehbeenhtakinghAdvilhforhmyhfoothforhahfewhdays.
Student:hWhathdidhyouhdohtohtreathyourhfootha erhyourhaccident?h-
hTinahJones:hIhmadehsurehtohcleanhithandhkeephithbandaged.hAndhIhputhNeosporinhonhit.
Student:hHowheffec vehwashthehNeosporin?h-hTinahJones:hWell,hI'mhhere,hsohIhguesshithdidn'thdohitshjob.
, Student:hCanhyouhwalkhwithhyourhfoothbeinghinjured?h-
hTinahJones:hNo,hIhcan't.hIhcan'thputhanyhweighthonhithwithouthlike,hshoo nghpain.
Student:hWhathpreexis nghmedicalhcondi onshdohyouhhave?h-
hTinahJones:hIhmean,hIhhavehasthmahandhdiabetes,hbuthrighthIhnowhIhjusthcarehabouthmyhfoot!
Student:hIhunderstandhyourhfoothhurts,hbuthIhneedhtohknowhthishinforma onhtohmakehsurehIhtakehcarehofhth
ehproblemhcorrectly.h-hTinahJones:hThanks.
Student:hWhenhwerehyouhdiagnosedhwithhdiabetes?h-hTinahJones:hIhwashdiagnosedhwhenhIhwash24.
Student:hWhathdohyouhdohtohmanagehyourhasthma?h-
hTinahJones:hIhtryhtohavoidhthingshthathgivehmehbreathinghproblems,hbuthwhenhmyhasthmahstartshtohacthup,hI
hjusthusehmyhinhaler.
Student:hWhathmedica onshdidhyouhtakehforhyourhdiabetes?h-hTinahJones:hIthwashme ormin.
Student:hDohyouhcurrentlyhtakehmedicinehforhyourhdiabetes?h-
hTinahJones:hNo,hIhdon'thtakehanythinghforhmyhdiabeteshanymore.
Student:hWhathmadehyouhstophtakinghmedica onhforhyourhdiabetes?h-
hTinahJones:hIhguesshIhjusthgothsickhofhfeelinghsickhandhgassyhallhtheh me,handhithwashoverwhelming,hremem
beringhtohtakehpillshandhcheckhmyhsugar.hIhfeelhahlothbe erhnowhthathI'mhjusthea nghhealthierhthanhIhdidhwh
enhIhwashtakinghthehpills.
Student:hDohyouhmonitorhyourhbloodhglucose?h-
hTinahJones:hIhhavehahmonitorhathhome,hbuthtohbehhonesthIhdon'threallyhusehiththatho en.
Student:hHowhfrequentlyhdohyouhurinate?h-hTinahJones:hIhdon'thknow.hEveryhhourhorhtwohwhenhI'mhawake?
Student:hWhathishyourhcurrenthdiet?h-
hTinahJones:hIt'shpre yhgood,hIhthink.hI'mhnothahhugehhealthhnuthorhanything.
h h h h h h
HealthhHistoryhTipsh&hTricks:h-hTJhHealthhInterview
Student:hHello!h-
hDianahShadow: hHi.hI'mhPreceptorhDiana.hIhwillhexplainhthehdetailshofhthishassignmenthandhyourhobjec ves,h
justhashahpreceptorhwouldhinhrealhlife.hPayhcloseha en onhtohthishinforma onhashithwillhhelphguidehyourhexa
m.hAththehendhofhthishprebrief,hyouhwillhanswerhahshorthques onhabouththehupcominghassignment.hDuringh
thehsimula on,hyouhmayhreturnhtohthesehinstruc onshathanyh mehbyhscrollinghtohthehtophofhyourhtranscript
.
Student:hWhathishthehsitua on?h-hDianahShadow:hYourhpa enthishTinahJones:,hah28-year-
oldhAfricanhAmericanhwomanhwhohhashjusthbeenhadmi edhtohShadowhGeneralhHospitalhforhahpainfulhfooth
wound.hYourhrolehinhthishsimula onhishthathofhahhealthcarehproviderhwhohwillhtakehMs.hJones'hhealthhhistor
y,hahkeyhcomponenthofhherhadmissionhprocess.
Student:hWhatharehmyhobjec veshinhthishassessment?h-
hDianahShadow: hAhhealthhhistoryhrequireshyouhtohaskhques onshrelatedhtohMs.hJones'hpasthandhpresenthhe
alth,hfromhherhcurrenthfoothwoundhtohherhpre-
exis nghcondi ons.hYouhwillhalsohwanthtohreviewhMs.hJones'hsystems,hpsychosocialhhistory,handhfamilyhme
dicalhhistory.hThesehassessmentshtogetherhwillhgivehyouhahcomprehensivehpicturehofhMs.hJones'hoverallhhe
alth.hIfhyouhdiscoverhanyhdiseasehstates,haskhabouthsymptomshandhthehpa ent'shexperienceshofhthem.hYour
hques oninghshouldhcoverhahbroadharrayhofhthehsymptoms'hcharacteris cs.hThroughouththehconversa on,h
youhshouldheducatehandhempathizehwithhMs.hJoneshwhenhappropriatehtohincreasehherhhealthhliteracyhandh
sensehofhwell-
being.hRegardlesshofhwhetherhyouhhavehassessedhMs.hJoneshpreviously,haskhallhques onshthatharehnecessar
yhforhobtaininghahcompletehhealthhhistory.hWhilehyouhshouldhcommunicatehwithhpa entshusinghaccessible,
heverydayhlanguage,hithishstandardhprac cehtohusehprofessionalhmedicalhterminologyheverywherehelse,hsuc
hhashinhdocumen nghphysicalhfindingshandhnursinghnotes.hYouhmayhcompletehthehexamhac vi eshinhanyhor
derhandhmovehbetweenhthemhashneeded.hA erhobtaininghMs.hJones'hhealthhhistory,hyouhwillhcompletehanhi
nforma onhprocessinghac vity.hYouhwillhiden fyhandhpriori zehdiagnoses,hthenhcreatehahplanhtohaddresshth
ehiden fiedhdiagnoses.
Student:hWhathelsehwillhthishexamhinvolve?h-
hDianahShadow: hYouhwillhcompletehnursinghtaskshtohprotecththehpa entshsafety,hprivacy,handhhealth.hYouhca
nhdocumenthyourhfindings,hincludinghvitalhsigns,hinhthehElectronichHealthhRecord.hThishrecordhprovideshnec
essaryhinforma onhforhhealthcarehprofessionalshwhohwillhcon nuehpa enthcare.hBesideshSubjec vehDatahC
,ollec on,handhEduca onhandhEmpathy,hthereharehac vi eshwithinhthehsimula onhthathprovidehvaluablehpr
ac cehforhtheirhreal-worldhcounterparts,hbuththeyharehnothautoma callyhgradedhbyhthehsimula on.
Student:hHowhwillhIhbehevaluated?h-
hDianahShadow: hInhthishassignment,hyouhwillhbehevaluatedhonhyourhSubjec vehDatahCollec on,hashwellhashy
ourhEduca onhandhEmpathy.hYourhsuccesshinhEduca onhandhEmpathyhishbasedhonhwhetherhyouhpromptlyhr
espondha erhiden fyinghahmomenthworthyhofhtherapeu chcommunica on.hThehevalua onhofhyourhintervi
ewhishdependenthonhhowhyouhwordhyourhques onshtherapeu callyhandhpreciselyhandhexplorehallhrelevanth
topicshwithhcomprehensivehbreadthhandhdepth.hYouhwillhalsohbehevaluatedhonhyourhabilityhtohcollecthdatah
andhformhnursinghdiagnoseshinhthehinforma onhprocessinghac vity.hThishassignmenthtakeshonhaveragehbet
weenh90handh110hminutes.hThishexamhmayhtakehlongerhthanhinhrealhlife,hbecausehinhthishsafehsimula on,hst
udentshofhallhexperiencehlevelshcanhtakeh mehtohhonehandhreviewhtheirhskills.hYouhcanhpausehandhresumeht
hehassignmenthathanyh me;hyourhworkhishalwayshsavedhautoma cally.
Student:hHowhdoeshthishassignmenthpreparehmehforhthehrealhworld?h-
hDianahShadow: hInhthishassessment,hyouhwillhbecomehfamiliarizedhwithhthehstructurehandhcontenthofhahheal
thhhistoryhexamhsohthathwithhreal-
lifehpa ents,hyouhcan:hºhaskheffec vehandhcomprehensivehques onshºhobtainhahthoroughhhealthhhistoryhºhe
valuatehthehpa ent'shriskhofhdisease,hinfec on,hinjury,handhcomplica onshºheducatehandhempathizehºhreflec
thonhyourhexperiencehandhiden fyhareashtohimprovehºhiden fyhandhpriori zehnursinghdiagnoseshºhandhdeve
lophahplanhtohaddresshnursinghdiagnoses.
DianahShadow:hInh1horh2hsentences,hanswerhthishques onhtohhelphpreparehforhthehupcominghexam:hWhyhis
hithimportanthtohobtainhahpa ent'shcompletehhealthhhistory?h-
hStudent:hSohthathyouhunderstandhifhthereharehanyhproblemshrelatedhtohtheirhchiefhcomplaint.hAlso,htohhelp
htreaththeirhcurrenthcondi on.
DianahShadow:hTimehtohbegin.h-h
Pa enthExamh-hVitalhSigns:h-
hHeight:h170hcm,hWeight:h90hkg,hBMI:h31,hRandomhbloodhglucose:h238,hTemperature:h102.4°hF,hBloodhpres
sure:h138/90hmmHg,hHearthrate:h90,hRespiratoryhrate:h18,hO2hsat:h98%
Pa enthExamh-hInterview:h-h
Student:hHello,hmyhnamehishCatlain,hIhamhyourhnursehtoday.h-hTinahJones:hHey.
,Student:hCanhyouhconfirmhyourhname?h-hTinahJones:hTinahJones:.
Student:hWhyhdidhyouhcomehinhtoday?h-
hTinahJones:hIhgoththishscrapehonhmyhfoothahwhilehago,handhithgothreallyhinfected.hIt'shkillinghme.
Student:hWhathaddi onalhsymptomshhavehyouhexperienced?h-
hTinahJones:hIhmean,hit'shallhredhandhswollen,handhthere'shpus,hithfeelshhot,hithhurtshlikehhell...hIt'shgothallhthat
hgoinghon.
Student:hCanhyouhratehyourhcurrenthpainhlevelhonhahscalehofh0htoh10?h-
hTinahJones:h...Likehah7.hIthhurtshahlot,hbuthwhateverhpainhmedhthehERhgavehmehishhelpinghahli lehbit.
Student:hPleasehdescribehthehpain.h-hTinahJones:hIt'shthrobbinghandhlike,hsharphifhIhtryhtohputhweighthonhit.
Student:hHowhdidhyouhhurthyourhfoot?h-
hTinahJones:hIhwashchanginghahlighthbulb,handhIhhadhtohusehourhli lehstepstoolhtohreachhit.hMyhfoothslidhoffhth
ehbo omhstephandhithgothallhscrapedhup.hIhdidn'threalizehhowhsharphthehedgehwas!
Student:hHashyourhfoothbeenhdraininghanyhliquids?h-hTinahJones:hYeah,hthere'shdefinitelyhpus.
Student:hWhathcolorhwashthehpus?h-hTinahJones:hIt's...hwhitehorhmaybehoff-white.
Student:hHowhhavehyouhtreatedhthehwound?h-
hTinahJones:hI'vehbeenhtakinghAdvilhforhmyhfoothforhahfewhdays.
Student:hWhathdidhyouhdohtohtreathyourhfootha erhyourhaccident?h-
hTinahJones:hIhmadehsurehtohcleanhithandhkeephithbandaged.hAndhIhputhNeosporinhonhit.
Student:hHowheffec vehwashthehNeosporin?h-hTinahJones:hWell,hI'mhhere,hsohIhguesshithdidn'thdohitshjob.
, Student:hCanhyouhwalkhwithhyourhfoothbeinghinjured?h-
hTinahJones:hNo,hIhcan't.hIhcan'thputhanyhweighthonhithwithouthlike,hshoo nghpain.
Student:hWhathpreexis nghmedicalhcondi onshdohyouhhave?h-
hTinahJones:hIhmean,hIhhavehasthmahandhdiabetes,hbuthrighthIhnowhIhjusthcarehabouthmyhfoot!
Student:hIhunderstandhyourhfoothhurts,hbuthIhneedhtohknowhthishinforma onhtohmakehsurehIhtakehcarehofhth
ehproblemhcorrectly.h-hTinahJones:hThanks.
Student:hWhenhwerehyouhdiagnosedhwithhdiabetes?h-hTinahJones:hIhwashdiagnosedhwhenhIhwash24.
Student:hWhathdohyouhdohtohmanagehyourhasthma?h-
hTinahJones:hIhtryhtohavoidhthingshthathgivehmehbreathinghproblems,hbuthwhenhmyhasthmahstartshtohacthup,hI
hjusthusehmyhinhaler.
Student:hWhathmedica onshdidhyouhtakehforhyourhdiabetes?h-hTinahJones:hIthwashme ormin.
Student:hDohyouhcurrentlyhtakehmedicinehforhyourhdiabetes?h-
hTinahJones:hNo,hIhdon'thtakehanythinghforhmyhdiabeteshanymore.
Student:hWhathmadehyouhstophtakinghmedica onhforhyourhdiabetes?h-
hTinahJones:hIhguesshIhjusthgothsickhofhfeelinghsickhandhgassyhallhtheh me,handhithwashoverwhelming,hremem
beringhtohtakehpillshandhcheckhmyhsugar.hIhfeelhahlothbe erhnowhthathI'mhjusthea nghhealthierhthanhIhdidhwh
enhIhwashtakinghthehpills.
Student:hDohyouhmonitorhyourhbloodhglucose?h-
hTinahJones:hIhhavehahmonitorhathhome,hbuthtohbehhonesthIhdon'threallyhusehiththatho en.
Student:hHowhfrequentlyhdohyouhurinate?h-hTinahJones:hIhdon'thknow.hEveryhhourhorhtwohwhenhI'mhawake?
Student:hWhathishyourhcurrenthdiet?h-
hTinahJones:hIt'shpre yhgood,hIhthink.hI'mhnothahhugehhealthhnuthorhanything.
